– DEMOGRAPHICS –

■ ■ 

■

■

 

 

– CLINICAL SIGNS,SYMPTOMS, AND OUTCOMES –

__ __ __ __ __ __ __ __ (mm/dd/yyyy) 

■ ■ ■

■ ■ 1 ■ YES 2 NO 9 Unk __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

 – LABORATORY DATA –

 

 Titer Positive? 

■ ■ ■

■ ■

■ ■ ■

■ ■ ■

■

– FINAL DIAGNOSIS –

 

 

 

 __ __ __ __ __ __ __ __ 

Patient's 

name: 

Physician’s 

Address: name: 

City: 

8. Indicate Disease (Presumed) To Be Reported: 

Specify condition(s): 

______________________________________________________ 

13. Was the patient hospitalized because of this illness? (If yes, date) 14. Did the patient die because of this illness? (If yes, date) 

1 YES 2 NO 

State Health Department Official who reviewed this report: 

Name: ____________________________________________________________ 

Title: __________________________________ Date: ____________________________________ 

(_____) 

(_____) 

_____

1. State of residence: 2. County of residence: 

5. Date of 

birth: 

(26-50) 3. Zip code: (51-59) 4. Sex: 

(24-25) 

6. Race: 7. Hispanic 

(70) 

(71) 

(121-130) 

1 Male 

2 Female 

American Indian 1 Yes 1 White 3 Alaskan Native 5 Pacific Islander 2 No 2 Black 4 Asian 9 Not specified 

1 YES 2 NO 9 Unk 

1 YES 2 NO 9 Unk 

Date submitted: 

(5-6) (7-8) (9-12) 

(number, street) 

NETSS ID No.: (if reported) 

(61-62) (63-64) (65-68) 

10. Date of Onset of Symptoms: 

11. Was an underlying immunosuppressive condition present? 12. Specify any life-threatening complications in the clinical course of illness: 

1 Adult respiratory distress syndrome (ARDS) 3 Meningitis/encephalitis 

2 Disseminated intravascular coagulopathy (DIC) 4 Renal failure 9 None 

8 Other: _______________________________________________________________ 

(93-94) (95-96) (97-100) 

__ __ __ __ __ __ __ __ (mm/dd/yyyy) 

(60) 

(69) 

__ __ __ __ __ __ __ __ (mm/dd/yyyy) 

(81) 

(83) (92) 

__ __ __ __ __ __ __ __ (mm/dd/yyyy) 

__ __ __ __ __ - __ __ __ __

__ __ 

(137) 

(138) 

(149) 

(139-148) 

__ __ __ __ __ __

15. Name of 

laboratory:________________________________________________ City:________________________________ State: __ __ Zip:

16. 

Serology 1 Positive? 

Titer Positive? PCR 

IFA - IgG Morulae visualization* 

Immunostain 

IFA - IgM Culture 

Other 

test: ______________ 

* Was there a fourfold change in antibody titer between the two serum specimens? 

COLLECTION DATE (mm/dd/yyyy) COLLECTION DATE (mm/dd/yyyy)

Serology 2* __ __ __ __ __ __ __ __ 

(109-10) (111-12) (113-16) 

1 YES 2 NO 

1 YES 2 NO 

1 YES 2 NO 

1 YES 2 NO 

1 YES 2 NO 

(mm/dd/yyyy) 

(117) (_____) 1 YES 2 NO (118) 

1 YES 2 NO (119) (_____) 1 YES 2 NO (120) 

( ) 1 YES 2 NO (131) (_____) 1 ■ YES 2 NO (132) 

(82) 

17. 

(133) 

(134) 

(135) 

(136) 

18. 

} 1 CONFIRMED 

2 PROBABLE 

Phone 

no.: 

Postal 

abrv: 

Case ID (13-18) Site (19-21) State (22-23) 

9 Unk

ethnicity: 

9 Unk 

1 3 Anaplasmosis - A. phagocytophilum 5 Ehrlichiosis/Anaplasmosis ­

2 Undetermined Ehrlichiosis - E. chaffeensis 4 Ehrlichiosis - E. ewingii 

(84-85) (86-87) (88-91) 

1 RMSF) 2 Ehrlichiosis -E. chaffeensis 

3 Anaplasmosis -A. phagocytophilum 4 Ehrlichiosis - E.ewingii 

5 Ehrlichiosis/Anaplasmosis - Undetermined 

-

History of travel outside county of residence within 30 days of onset of symptoms?: 1 YES 2 NO 9 Unk 

SFR (including RMSF) 

9. Was a clinically compatible illness present? (72) 

1 YES 2 NO 9 Unk 

Eschar (aka tache noire) or black, necrotic area around site of known/possible tick bite present? 1 YES 2 NO 9 Unk (73-80) 

SFR (including

(101-2) (103-4) (105-8) 

COMMENTS: 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

 

– PATIENT/PHYSICIAN INFORMATION –

 

CDC CASE DEFINITIONS

Tick-Borne Rickettsial Disease Case Report 

Use for: Spotted fever rickettsiosis (SFR) including Rocky Mountain spotted fever (RMSF), 


Ehrlichiosis (E. chaffeensis, E. ewingii, & undet.), and Anaplasmosis (A. phagocytophilum & undet.). 


Visit and use "Search" for complete Case Definition(s) or 

visit the disease web site(s) for a fillable/downloadable PDF version of this Case Report.

http://www.cdc.gov

DEPARTMENT OF HEALTH & HUMAN SERVICES 

Centers for Disease Control 

and Prevention (CDC) 

Atlanta, Georgia 30333 

Form Approved 

CDC# (1-4) OMB 0920-0009

&'&( 5HYLVHG2FWREHU&'&$GREH$FUREDW(OHFWURQLF9HUVLRQ2FWREHU TICK-BORNE RICKETTSIAL DISEASE CASE REPORT 

Confirmed SFR (including RMSF ) : A clinically compatible case with evidence of a fourfold change 

in IgG antibody titer reactive with Rickettsia rickettsii or other SFR antigens by IFA between paired serum 

specimens, one taken during the first week of illness and a second 2-4 weeks later, OR detection of R. rickettsial 

or other SFR DNA in a clinical specimen via ampli fication of a specific target by PCR assay, OR demonstration of 

SFR antigen in a biopsy/autopsy specimen by IHC, OR isolation of R. rickettsia or other SFR species from a 

clinical specimen in cell culture. 

Probable SFR (including RMSF): A clinically compatible case with evidence of elevated IgG or 

IgM antibody reactive with R. rickettsii or other SFR antigens by IFA, enzyme-linked immunosorbent assay (ELISA), 

dot-ELISA, or latex agglutination (CDC uses an IFA IgG cutoff of ≥1:64 and does not use IgM test results as 

independent diagnostic support criteria.). 

Note: Current commercially available ELISA tests cannot evaluate changes in antibody titer. IgM tests may be unreliable because they lack specificity. IgM antibody may persist for lengthy periods of time. When sera 

demonstrate elevated antibody responses to multiple infectious agents among rickettsial species, and between 

ehrlichial and anaplasmal species, the greater antibody response is generally directed at the actual agent involved.

 

If there is no presence of clinical illness, then this is not a case. 

Clinical evidence - fever and one or more of the following: rash (primarily SFR), headache, 

myalgia, anemia, leukopenia (Ehrlich. & Anaplas.), thrombocytopenia, or elevated hepatic transaminases. 

Below, indicate Y (Yes) or N (No), ONLY if the test or procedure was performed. Lack of selection indicates that the test or procedure was not performed. 

Serologic 

Tests 

Other Diagnostic Test?

(Use # 16, S1 for collection date) 

* Visualization of morulae not applicable for SFR. 

Classify case BASED ON the CDC case definition (see criteria below): 

Confirmed Ehrlichiosis/Anaplasmosis: A clinically compatible case with evidence of a fourfold

change in IgG antibody titer reactive with Ehrlichia chaffeensis or Anaplasma phagocytophilum antigen by

IFA between paired serum specimens (one taken during the first week of illness and a second 2-4 weeks later)

OR detection of E. chaffeensis or A. phagocytophilum DNA in a clinical specimen via amplification of

a specific target by PCR assay, OR demonstration of ehrlichial or anaplasmal antigen in a biospy/autopsy

specimen by IHC, OR isolation of E. chaffeensis or A. phagocytophilum from a clinical specimen in cell culture.

Probable Ehrlichiosis/Anaplasmosis: A clinically compatible case with evidence of elevated IgG

or IgM antibody reactive with E. chaffeensis or A. phagocytophilum antigen by IFA, enzyme-linked immunosorbent

assay (ELISA), dot-ELISA, or assays in other formats (CDC uses an IFA IgG cutoff of ≥1:64 and does not use IgM

test results as independent diagnostic support criteria.), OR identification of morulae in the cytoplasm of monocytes

or macrophages (Ehrlichiosis) or in the cytoplasm of neutrophils or eosinophils (Anaplasmosis) by microscopic examination.

Public reporting burden of this collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, 

a collection of information unless it displays a currently valid OMB control number. Please send comments regarding this burden estimate or any other aspect of this collection of information, 

including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-74); Atlanta, GA30333; ATTN: PRA(0920-0009). 

1st COPY – STATE HEALTH DEPARTMENT 
 

 

GRAPHICS –

■ ■ 

■

■

 

 

– CLINICAL SIGNS,SYMPTOMS, AND OUTCOMES –

__ __ __ __ __ __ __ __ (mm/dd/yyyy) 

■ ■ ■

■ ■ 1 ■ YES 2 NO 9 Unk __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

 – LABORATORY DATA –

 

 Titer Positive? 

■ ■ ■

■ ■

■ ■ ■

■ ■ ■

■

– FINAL DIAGNOSIS –

 

 

 

 __ __ __ __ __ __ __ __ 

– DEMO

Patient's 

name: 

Ph

Address: na

City: 

Dat

(number, street) 

NE

4KHgklOIjHbMgXijnUkjbBnjIoiFt9bFjnjROIjHbMgjTgiNmZhGphKDvjRbWkgjTgiNmZhGphKDvjRbWk4KHygnjTgiNmZhGphKDvjRbWkgnjTgiNmZhGphKDvjRbWkg4KBnjIoiFt9bFjnygnjTgiNmZhGph KDvjRbWkgjTgiNmZhGphKDvjRbWkg4KngklZhGgiNmZhGphKDvjRbWkg4KngklOBHbMgXijnUkjbBnjIoiFt9bFjTgiNmvjROIjHbMgXijn9bFjnjTgiNmWkgjTgiNkZhBphKDvjRbWkg4KkgklOIjHbMgXijn U9bFjnjTgiNmZhHphKDvjRbWkgnjTgiNmZhGphKDvjRbWkgOBHbMgXijnUkjbBnUkjbBnjIoiFt9bFjnkgnjTgiNmZhGphgklOIjHbMgXijUkjbBnjIoiFtkjbBnjIoiFtngklOIjHbMgXijnUkjbkgkjnUkjZhGphiFt9bFjnjTgiNmZhGph KDvjRbWKDphKDvjRbWkgnjTbWkg4KMgklygkKDvjRbZhGphjROIjHbMgOIjHbMgXijhKDvjRHbMgXijUkjbBnjIoiFOIjHbMgXijnhKDvjRbWkZhGphKDvjRbWkROIjHbMgXiijUkjbBngWjB kNkZXijUkjbOIjHbMgXijnhKDvjRbnjIoiFtgiNmZhGphKDvkgOIjHbWkgjTgiNkZhBphKDvjRbIjHbMgXijUkjbZhBphiFt9bFjnjIoiFtkjbBjHbMgXijn9bFjnjTbWkg4iFt9bFjnjTgiNUkjbBnjIoiFtkjbBnjIoiFtngklOIjHbMgXijnUkjbZgkjnBkjZhBphiFt9bFjnj TgiNHZhGphKDvjRbWKDphKDvjRbWkgnjTUkjbBkjIoiFtkjbBnjIoiFtngklOIjHbMgXijnUkjbkgkjnUkjZhGphiFtkZkbMgXijUkjbBnjIoiFtkjbBnjIoiFtngklOIjHbMgXijnUkjbkgkjnUkjZhGphiFt9bFjnjTgiNmZhGphKDvjRbWKDphK DvjRbWkgnjTbWkg4KMgklygkKDvjRbZhGphjROIjHbMgOIjHbMgXijhKDvjRHbMgXijUkjbBnjIoiFOIjHBhKKDvjRbZhGphjROIjHbMgOIjHbMgXijhKDvjRHbMgXijUkjbBnjIoiFOIjHbMgXijnhKDvjR bWkZhGphKDvjRbWkROIjHbMgXiijUkjbBngWjBkNkZXinjTgiNmZhGphKDvjRbWKDphKDvjRbWkgnjTbWkg4KMgklygkKDvjRbZhGphjROIjHbMgOIjHbMgXijhKDvjRHbMgXijUkjb BnjIoiFOIjHBhKKDvjRbZhGphjROIjHbMgOIjHbMgXijhKDvjRHbMgXijUkjbBnjIoiFOIjHbMgXijnhKDvjRbWkZhGphKDvjRbWkROIjHbMgXiijUkjbBngWjBkNRbIjHbMgXijUkjbZhBphiFt9bFjnjIoiFtkjbBjHb MgXijn9bFjnjTbWkg4iFt9bFjnjTgiNUkjbBnjIoiFtkjbBnjIoiFtngklOIjHbMgXijnUkjbZgkjnBkjZhBphiFt9bFjnjTgiNHZhGphKBvjRbWkg4KkgklOIjHbMgXijnU9bFjnjTgiNmZhHphKDvjRbWkgnjTgiNmZhGphKDvjRbWkgOBH bMgXijnUkjbBnUkjbBnjIoiFt9bFjnkgnjTgiNmZhGphgklOIjHbMgXijUkjbBnjIoiFtkjbBnjIoiFtngklOIjHbMgXijnUkjbkgkjnUkjZhGphiFt9bFjnjTgikjbBnjIoiFtkjbBnjIoiFtngklOIjHbMgXijnUkjbkgkjnUkjZhGphiFt9bFjnjTgiNmZhGphKDvjRbWKDphKDvj RbWkgnjTbWkg4KMgklygkKDvjRbZhGphjROIjHbMgOIjHbMgXijhKDvjRHbMgXijUkjbBnjIoiFOIjHBhKKDvjRbZhGphjROIjHbMgOIjHbMgXijhKDvjRHbMgXijUkjbBnjIoiFOIjHbMgXijnhKDvjRb WkZhGphKDvjRbWkROIjHbMgXiijUkjbBngWjBkNkZXinjTgiNmZhGphKDvjRbWKDphKDvjRbWkgnjTbWkg4KMgklygkKDvjRbZhGphjROIjHbMgOIjHbMgXijhKDvjRHbMgXijUkjnFjnj

ysician’s 

me: 

8. Indicate Disease (Presumed) To Be Reported: 

Specify condition(s): 

______________________________________________________ 

13. Was the patient hospitalized because of this illness? (If yes, date) 14. Did the patient die because of this illness? (If yes, date) 

1 YES 2 NO 

State Health Department Official who reviewed this report: 

Name: ____________________________________________________________ 

Title: __________________________________ Date: ____________________________________ 

(_____) 

(_____) 

_____

1. State of residence: 2. County of residence: 

5. Date of 

birth: 

(26-50) 3. Zip code: (51-59) 4. Sex: 

(24-25) 

6. Race: 7. Hispanic 

(70) 

(71) 

(121-130) 

1 Male 

2 Female 

American Indian 1 Yes 1 White 3 Alaskan Native 5 Pacific Islander 2 No 2 Black 4 Asian 9 Not specified 

1 YES 2 NO 9 Unk 

1 YES 2 NO 9 Unk 

e submitted: 

(5-6) (7-8) (9-12) 

TSS ID No.: (if reported) 

(61-62) (63-64) (65-68) 

10. Date of Onset of Symptoms: 

11. Was an underlying immunosuppressive condition present? 12. Specify any life-threatening complications in the clinical course of illness: 

1 Adult respiratory distress syndrome (ARDS) 3 Meningitis/encephalitis 

2 Disseminated intravascular coagulopathy (DIC) 4 Renal failure 9 None 

8 Other: _______________________________________________________________ 

(93-94) (95-96) (97-100) 

__ __ __ __ __ __ __ __ (mm/dd/yyyy) 

(60) 

(69) 

__ __ __ __ __ __ __ __ (mm/dd/yyyy) 

(81) 

(83) (92) 

__ __ __ __ __ __ __ __ (mm/dd/yyyy) 

__ __ __ __ __ - __ __ __ __

__ __ 

(137) 

(138) 

(149) 

(139-148) 

__ __ __ __ __ __

15. Name of 

laboratory:________________________________________________ City:________________________________ State: __ __ Zip:

16. 

Serology 1 Positive? 

Titer Positive? PCR 

IFA - IgG Morulae visualization* 

Immunostain 

IFA - IgM Culture 

Other 

test: ______________ 

* Was there a fourfold change in antibody titer between the two serum specimens? 

COLLECTION DATE (mm/dd/yyyy) COLLECTION DATE (mm/dd/yyyy)

Serology 2* __ __ __ __ __ __ __ __ 

(109-10) (111-12) (113-16) 

1 YES 2 NO 

1 YES 2 NO 

1 YES 2 NO 

1 YES 2 NO 

1 YES 2 NO 

(mm/dd/yyyy) 

(117) (_____) 1 YES 2 NO (118) 

1 YES 2 NO (119) (_____) 1 YES 2 NO (120) 

( ) 1 YES 2 NO (131) (_____) 1 ■ YES 2 NO (132) 

(82) 

17. 

(133) 

(134) 

(135) 

(136) 

18. 

} 1 CONFIRMED 

2 PROBABLE 

Phone 

no.: 

Postal 

abrv: 

Case ID (13-18) Site (19-21) State (22-23) 

9 Unk

ethnicity: 

9 Unk 

1 3 Anaplasmosis - A. phagocytophilum 5 Ehrlichiosis/Anaplasmosis ­

2 Undetermined Ehrlichiosis - E. chaffeensis 4 Ehrlichiosis - E. ewingii 

(84-85) (86-87) (88-91) 

1 RMSF) 2 Ehrlichiosis -E. chaffeensis 

3 Anaplasmosis -A. phagocytophilum 4 Ehrlichiosis - E.ewingii 

5 Ehrlichiosis/Anaplasmosis - Undetermined 

-

History of travel outside county of residence within 30 days of onset of symptoms?: 1 YES 2 NO 9 Unk 

SFR (including RMSF) 

9. Was a clinically compatible illness present? (72) 

1 YES 2 NO 9 Unk 

Eschar (aka tache noire) or black, necrotic area around site of known/possible tick bite present? 1 YES 2 NO 9 Unk (73-80) 

SFR (including

(101-2) (103-4) (105-8) 

COMMENTS: 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

 

– PATIENT/PHYSICIAN INFORMATION –

 

CDC CASE DEFINITIONS

Tick-Borne Rickettsial Disease Case Report 

Use for: Spotted fever rickettsiosis (SFR) including Rocky Mountain spotted fever (RMSF), 


Ehrlichiosis (E. chaffeensis, E. ewingii, & undet.), and Anaplasmosis (A. phagocytophilum & undet.). 


Visit and use "Search" for complete Case Definition(s) or 

visit the disease web site(s) for a fillable/downloadable PDF version of this Case Report.

http://www.cdc.gov

DEPARTMENT OF HEALTH & HUMAN SERVICES 

Centers for Disease Control 

and Prevention (CDC) 

Atlanta, Georgia 30333 

Form Approved 

CDC# (1-4) OMB 0920-0009

&'&( 5HYLVHG2FWREHU&'&$GREH$FUREDW(OHFWURQLF9HUVLRQ2FWREHU TICK-BORNE RICKETTSIAL DISEASE CASE REPORT 

Confirmed SFR (including RMSF ) : A clinically compatible case with evidence of a fourfold change 

in IgG antibody titer reactive with Rickettsia rickettsii or other SFR antigens by IFA between paired serum 

specimens, one taken during the first week of illness and a second 2-4 weeks later, OR detection of R. rickettsial 

or other SFR DNA in a clinical specimen via ampli fication of a specific target by PCR assay, OR demonstration of 

SFR antigen in a biopsy/autopsy specimen by IHC, OR isolation of R. rickettsia or other SFR species from a 

clinical specimen in cell culture. 

Probable SFR (including RMSF): A clinically compatible case with evidence of elevated IgG or 

IgM antibody reactive with R. rickettsii or other SFR antigens by IFA, enzyme-linked immunosorbent assay (ELISA), 

dot-ELISA, or latex agglutination (CDC uses an IFA IgG cutoff of ≥1:64 and does not use IgM test results as 

independent diagnostic support criteria.). 

Note: Current commercially available ELISA tests cannot evaluate changes in antibody titer. IgM tests may be unreliable because they lack specificity. IgM antibody may persist for lengthy periods of time. When sera 

demonstrate elevated antibody responses to multiple infectious agents among rickettsial species, and between 

ehrlichial and anaplasmal species, the greater antibody response is generally directed at the actual agent involved. 

If there is no presence of clinical illness, then this is not a case. 

Clinical evidence - fever and one or more of the following: rash (primarily SFR), headache, 

myalgia, anemia, leukopenia (Ehrlich. & Anaplas.), thrombocytopenia, or elevated hepatic transaminases. 

Below, indicate Y (Yes) or N (No), ONLY if the test or procedure was performed. Lack of selection indicates that the test or procedure was not performed. 

Serologic 

Tests 

Other Diagnostic Test?

(Use # 16, S1 for collection date) 

* Visualization of morulae not applicable for SFR. 

Classify case BASED ON the CDC case definition (see criteria below): 

Confirmed Ehrlichiosis/Anaplasmosis: A clinically compatible case with evidence of a fourfold

change in IgG antibody titer reactive with Ehrlichia chaffeensis or Anaplasma phagocytophilum antigen by

IFA between paired serum specimens (one taken during the first week of illness and a second 2-4 weeks later)

OR detection of E. chaffeensis or A. phagocytophilum DNA in a clinical specimen via amplification of

a specific target by PCR assay, OR demonstration of ehrlichial or anaplasmal antigen in a biospy/autopsy

specimen by IHC, OR isolation of E. chaffeensis or A. phagocytophilum from a clinical specimen in cell culture.

Probable Ehrlichiosis/Anaplasmosis: A clinically compatible case with evidence of elevated IgG

or IgM antibody reactive with E. chaffeensis or A. phagocytophilum antigen by IFA, enzyme-linked immunosorbent

assay (ELISA), dot-ELISA, or assays in other formats (CDC uses an IFA IgG cutoff of ≥1:64 and does not use IgM

test results as independent diagnostic support criteria.), OR identification of morulae in the cytoplasm of monocytes

or macrophages (Ehrlichiosis) or in the cytoplasm of neutrophils or eosinophils (Anaplasmosis) by microscopic examination.

Public reporting burden of this collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, 

a collection of information unless it displays a currently valid OMB control number. Please send comments regarding this burden estimate or any other aspect of this collection of information, 

including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-74); Atlanta, GA30333; ATTN: PRA(0920-0009). 

 2nd COPY – CDC 
 

 

– DEMOGRAPHICS –

■ ■ 

■

■

 

 

– CLINICAL SIGNS,SYMPTOMS, AND OUTCOMES –

__ __ __ __ __ __ __ __ (mm/dd/yyyy) 

■ ■ ■

■ ■ 1 ■ YES 2 NO 9 Unk __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

 – LABORATORY DATA –

 

 Titer Positive? 

■ ■ ■

■ ■

■ ■ ■

■ ■ ■

■

– FINAL DIAGNOSIS –

 

 

 

 __ __ __ __ __ __ __ __ 

Patient's 

name: 

Physician’s 

Address: name: 

City: 

8. Indicate Disease (Presumed) To Be Reported: 

Specify condition(s): 

______________________________________________________ 

13. Was the patient hospitalized because of this illness? (If yes, date) 14. Did the patient die because of this illness? (If yes, date) 

1 YES 2 NO 

State Health Department Official who reviewed this report: 

Name: ____________________________________________________________ 

Title: __________________________________ Date: ____________________________________ 

(_____) 

(_____) 

_____

1. State of residence: 2. County of residence: 

5. Date of 

birth: 

(26-50) 3. Zip code: (51-59) 4. Sex: 

(24-25) 

6. Race: 7. Hispanic 

(70) 

(71) 

(121-130) 

1 Male 

2 Female 

American Indian 1 Yes 1 White 3 Alaskan Native 5 Pacific Islander 2 No 2 Black 4 Asian 9 Not specified 

1 YES 2 NO 9 Unk 

1 YES 2 NO 9 Unk 

Date submitted: 

(5-6) (7-8) (9-12) 

(number, street) 

NETSS ID No.: (if reported) 

(61-62) (63-64) (65-68) 

10. Date of Onset of Symptoms: 

11. Was an underlying immunosuppressive condition present? 12. Specify any life-threatening complications in the clinical course of illness: 

1 Adult respiratory distress syndrome (ARDS) 3 Meningitis/encephalitis 

2 Disseminated intravascular coagulopathy (DIC) 4 Renal failure 9 None 

8 Other: _______________________________________________________________ 

(93-94) (95-96) (97-100) 

__ __ __ __ __ __ __ __ (mm/dd/yyyy) 

(60) 

(69) 

__ __ __ __ __ __ __ __ (mm/dd/yyyy) 

(81) 

(83) (92) 

__ __ __ __ __ __ __ __ (mm/dd/yyyy) 

__ __ __ __ __ - __ __ __ __

__ __ 

(137) 

(138) 

(149) 

(139-148) 

__ __ __ __ __ __

15. Name of 

laboratory:________________________________________________ City:________________________________ State: __ __ Zip:

16. 

Serology 1 Positive? 

Titer Positive? PCR 

IFA - IgG Morulae visualization* 

Immunostain 

IFA - IgM Culture 

Other 

test: ______________ 

* Was there a fourfold change in antibody titer between the two serum specimens? 

COLLECTION DATE (mm/dd/yyyy) COLLECTION DATE (mm/dd/yyyy)

Serology 2* __ __ __ __ __ __ __ __ 

(109-10) (111-12) (113-16) 

1 YES 2 NO 

1 YES 2 NO 

1 YES 2 NO 

1 YES 2 NO 

1 YES 2 NO 

(mm/dd/yyyy) 

(117) (_____) 1 YES 2 NO (118) 

1 YES 2 NO (119) (_____) 1 YES 2 NO (120) 

( ) 1 YES 2 NO (131) (_____) 1 ■ YES 2 NO (132) 

(82) 

17. 

(133) 

(134) 

(135) 

(136) 

18. 

} 1 CONFIRMED 

2 PROBABLE 

Phone 

no.: 

Postal 

abrv: 

Case ID (13-18) Site (19-21) State (22-23) 

9 Unk

ethnicity: 

9 Unk 

1 3 Anaplasmosis - A. phagocytophilum 5 Ehrlichiosis/Anaplasmosis ­

2 Undetermined Ehrlichiosis - E. chaffeensis 4 Ehrlichiosis - E. ewingii 

(84-85) (86-87) (88-91) 

1 RMSF) 2 Ehrlichiosis -E. chaffeensis 

3 Anaplasmosis -A. phagocytophilum 4 Ehrlichiosis - E.ewingii 

5 Ehrlichiosis/Anaplasmosis - Undetermined 

-

History of travel outside county of residence within 30 days of onset of symptoms?: 1 YES 2 NO 9 Unk 

SFR (including RMSF) 

9. Was a clinically compatible illness present? (72) 

1 YES 2 NO 9 Unk 

Eschar (aka tache noire) or black, necrotic area around site of known/possible tick bite present? 1 YES 2 NO 9 Unk (73-80) 

SFR (including

(101-2) (103-4) (105-8) 

COMMENTS: 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

 

– PATIENT/PHYSICIAN INFORMATION –

 

CDC CASE DEFINITIONS

Tick-Borne Rickettsial Disease Case Report 

Use for: Spotted fever rickettsiosis (SFR) including Rocky Mountain spotted fever (RMSF), 


Ehrlichiosis (E. chaffeensis, E. ewingii, & undet.), and Anaplasmosis (A. phagocytophilum & undet.). 


Visit and use "Search" for complete Case Definition(s) or 

visit the disease web site(s) for a fillable/downloadable PDF version of this Case Report.

http://www.cdc.gov

DEPARTMENT OF HEALTH & HUMAN SERVICES 

Centers for Disease Control 

and Prevention (CDC) 

Atlanta, Georgia 30333 

Form Approved 

CDC# (1-4) OMB 0920-0009

&'&( 5HYLVHG2FWREHU&'&$GREH$FUREDW(OHFWURQLF9HUVLRQ2FWREHU TICK-BORNE RICKETTSIAL DISEASE CASE REPORT 

Confirmed SFR (including RMSF ) : A clinically compatible case with evidence of a fourfold change 

in IgG antibody titer reactive with Rickettsia rickettsii or other SFR antigens by IFA between paired serum 

specimens, one taken during the first week of illness and a second 2-4 weeks later, OR detection of R. rickettsial 

or other SFR DNA in a clinical specimen via ampli fication of a specific target by PCR assay, OR demonstration of 

SFR antigen in a biopsy/autopsy specimen by IHC, OR isolation of R. rickettsia or other SFR species from a 

clinical specimen in cell culture. 

Probable SFR (including RMSF): A clinically compatible case with evidence of elevated IgG or 

IgM antibody reactive with R. rickettsii or other SFR antigens by IFA, enzyme-linked immunosorbent assay (ELISA), 

dot-ELISA, or latex agglutination (CDC uses an IFA IgG cutoff of ≥1:64 and does not use IgM test results as 

independent diagnostic support criteria.). 

Note: Current commercially available ELISA tests cannot evaluate changes in antibody titer. IgM tests may be unreliable because they lack specificity. IgM antibody may persist for lengthy periods of time. When sera 

demonstrate elevated antibody responses to multiple infectious agents among rickettsial species, and between 

ehrlichial and anaplasmal species, the greater antibody response is generally directed at the actual agent involved. 

If there is no presence of clinical illness, then this is not a case. 

Clinical evidence - fever and one or more of the following: rash (primarily SFR), headache, 

myalgia, anemia, leukopenia (Ehrlich. & Anaplas.), thrombocytopenia, or elevated hepatic transaminases. 

Below, indicate Y (Yes) or N (No), ONLY if the test or procedure was performed. Lack of selection indicates that the test or procedure was not performed. 

Serologic 

Tests 

Other Diagnostic Test?

(Use # 16, S1 for collection date) 

* Visualization of morulae not applicable for SFR. 

Classify case BASED ON the CDC case definition (see criteria below): 

Confirmed Ehrlichiosis/Anaplasmosis: A clinically compatible case with evidence of a fourfold

change in IgG antibody titer reactive with Ehrlichia chaffeensis or Anaplasma phagocytophilum antigen by

IFA between paired serum specimens (one taken during the first week of illness and a second 2-4 weeks later)

OR detection of E. chaffeensis or A. phagocytophilum DNA in a clinical specimen via amplification of

a specific target by PCR assay, OR demonstration of ehrlichial or anaplasmal antigen in a biospy/autopsy

specimen by IHC, OR isolation of E. chaffeensis or A. phagocytophilum from a clinical specimen in cell culture.

Probable Ehrlichiosis/Anaplasmosis: A clinically compatible case with evidence of elevated IgG

or IgM antibody reactive with E. chaffeensis or A. phagocytophilum antigen by IFA, enzyme-linked immunosorbent

assay (ELISA), dot-ELISA, or assays in other formats (CDC uses an IFA IgG cutoff of ≥1:64 and does not use IgM

test results as independent diagnostic support criteria.), OR identification of morulae in the cytoplasm of monocytes

or macrophages (Ehrlichiosis) or in the cytoplasm of neutrophils or eosinophils (Anaplasmosis) by microscopic examination.

Public reporting burden of this collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, 

a collection of information unless it displays a currently valid OMB control number. Please send comments regarding this burden estimate or any other aspect of this collection of information, 

including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-74); Atlanta, GA30333; ATTN: PRA(0920-0009). 

3rd COPY – LOCAL HEALTH DEPARTMENT